There is a growing conversation about Acne in relation to Polycystic Ovarian Syndrome (PCOS). Experienced practitioners such as Fiona Trup are focusing on the importance of this link and this blog post will cover the latest findings on PCOS, how to evaluate the condition using functional testing and the most effective treatment options.
Is it PCOS?
Polycystic Ovary Syndrome (PCOS) was first described over 85 years ago and is often missed or misdiagnosed, even though it is the single most common oligo-or anovulatory, hyperandrogenism and endocrinologic disorder in the female population who are of reproductive age and affects 6 to 10% of that population (Wolf, 2018).
The NIH recommended that the title PCOS should be changed to HA-PODS (Khadilkar 2016) i.e. “hyperandrogenic Persistent Ovulatory Dysfunction Syndrome as the name PCOS causes confusion and doesn’t reflect the complex metabolic hypothalamic pituitary ovarian and adrenal interactions that characterize the syndrome. (Roe, 2011).
Even more frustrating is the misconception from healthcare providers that PCOS sufferers should be overweight when according to Goyal 2017 one-third to one-half of women with PCOS are at normal or even underweight.
The Aetiology of PCOS
The cause of PCOS is still unknown, although genetic and environmental factors play a key role in the aetiology of the syndrome. Contributing environmental disruptors mimic and inhibit endogenous steroids which are associated with increased oxidative stress and inflammation. Pro inflammatory stimuli of the ovarian theca cell steroidogenic enzyme cause overproduction of androgens, owing to mRNA expression, as well as defects which might contribute to development of PCOS (Rosenfield, 2016).
Generally, PCOS is associated with a number of existing health conditions, including low grade chronic inflammation. It is also associated with the presence of metabolic issues such as insulin resistance; creating a risk of non-alcoholic fatty liver disease and obesity. Further, it is additionally associated with poor ovarian and hormonal function. Yet many women with PCOS symptoms may have adequate ovarian function, without cysts or insulin resistance. This is mainly due to the fact that DHEA/DHEA-s and androstenedione driven by the HPA axis may be converted to testosterone by peripheral tissues within the body, without involving the ovaries or insulin.
Adrenal androgen excess in women with PCOS seems to be linked to HPA axis dysregulation. PCOS patients produce excess pregnenolone and DHEA from the adrenal cortex and in response to pituitary ACTH (adrenocorticotropic hormone) (Kumar, 2005). That is associated with increased oxidative stress and inflammation, due to pro inflammatory stimuli of the ovarian theca cell. Steroidogenic enzymes overproduce androgens as a resultant from mRNA expression as well as defects which might contribute to the development of PCOS) (Rosenfield, 2016). The overproduction of Androgens (metabolites of testosterone) in PCOS can get converted to the more potent form of testosterone DHT dihydrotestosterone which, in most cases, results in issues of acne.
The presentation of PCOS / Acne
In PCOS, pituitary gland signalling often gets disturbed, and as this is the signalling pathway for the production of hormones, PCOS sufferers potentially have reduced levels of progesterone and oestrogen – with increased levels of testosterone. As a result of disturbed signalling, the sebaceous glands (an endocrine organ with a close association with the hair follicles known as a pilosebaceous unit) can increase in size, leading to elevated sebum excretion; which is part of the pathophysiology of acne.
The process involves Linoleic acid – a component of sebum found in the hair follicle – and this tends to dilute, disrupting the normal sloughing of the skin. In contrast, triglycerides and wax/cholesterol esters increased. (Pappas, 2009) This combination of the now sticky sebum and the unremoved dead skin cells creates the perfect environment for acne to grow and flourish. The environment created is suitable for the colonisation of microbial C Acnes, (cutibacterium) a lipophilic anaerobic gram-positive bacterium responsible for inflammation, papules, pustules, nodules and cysts.
Using Functional Testing to support PCOS / Acne clients
Aside from conventional scan testing, it is important to identify biomarker and system status. The one essential tool that FDX Practitioner Fiona Trup uses with all her clients is FDX blood and health reporting. She swears by the FDX Ultra and Female panels as these provide over 85 biomarkers, including hormones along with SHBG, assessments of glycaemic management and iron.
Supporting PCOS / Acne holistically
The implementation of a wholistic approach to the presentation of acne involves addressing the condition from the inside out, as well as the outside in. There are programs for both, and a regimen of balancing lifestyle, good diet and appropriate supplementation and application produces good results.
Fiona’s recommendations of supplements including herbals
- Vitamin D3, 50000 IU with 2000 mg fish oil markedly lowered serum testosterone with improvement in stress, inflammatory biomarkers and oxidative stress makers (Jamilian et al 2018)
- Fatty acids, see Vit D (Jamilian et al2018)
- Zinc 50mg a day taken at night on an empty stomach to improve the side effect of hirsutism and Cystic Acne resulted in in improving Malondialdehyde Plasma markers. Combining Zinc with Saw Palmetto can help reduce enzyme 5-alpha-reductase that converts testosterone to DHT.
- Inositol is an intracellular messenger responsible or signalling. (my-inositol/di-chiro inositol was used in a 2018 meta-analysis and showed to improve markers of insulin resistance, regulate menstrual cycles, improve ovulation and induce metabolic changes in PCOS. Dosage 1.2 to 4 grams per day
- NAC Improves insulin sensitivity and fertility (Fulghesu et al 2002)
- Magnesium, low levels contribute to insulin resistance and cvd, supplementation improves glucose uptake and avoids type 2 diabetes (Rodriguez and Romero 2003)
- Lipoic Acid improves glucose uptake and reduces oxidative stress markers (Mazloom et al 2011)
- Retinol thousands of studies show retinoids as efficacious in the treatment of inflammatory and non-inflammatory acne lesions (Leyden et al 2017)
- Chromium 400mcg improves acne (McCarty M 1984), reduces IR in PCOS and stimulates ovulation (Ashouf et all 2015)
- Spearmint (Mentha spicata) anti-androgenic properties reduce the level of free testosterone in the blood while leaving total testosterone and DHEAS unaffected. (Grant P 2010)
- Saw palmetto (see zinc), reduces DHT levels reducing the oils leading to acne (Dobrev 2007) (Reddy & Bubna 2017)
- Flaxseeds lignans reduce androgen levels, stimulates SHBG synthesis (Broadhurst et al 2000)
- Cinnamon extracts from bark function as antioxidants and potentiate insulin action (Anderson et al 2004)
- Pomegranate juice with synbiotics. Pomegranate juice enriched with probiotics weekly resulted in a reduction of serum testosterone leading to an improvement in acne, hirsutism and oligo/anovulation (Esmaeilinezhad, Z, 2018).
Fiona’s Acne /PCOS diet and lifestyle tips
- A whole food, anti-inflammatory low glycaemic diet to bring hormones back into balance.
- Low saturated fats, monounsaturated fat diets increase insulin sensitivity.
- Increase fibre intake.
- Fatty fish rich in omegas, including salmon, sardines and mackerel – these are anti-inflammatory.
- Daily intake of leafy green vegetables for zinc and magnesium, to help scarring and healing. Cruciferous vegetables such as broccoli, kale and Brussels sprouts contain indole-3-carbinol, which is converted to Diindolylmethane (DIM) by stomach acid and is a potent aromatase inhibitor.
- Retinoids (retinol) are fat soluble the bioavailable form of vitamin A, a potent antioxidant and is found in animal products. Carotenoids are found in plant foods such as carrots, butternut squash and sweet.
- Exercise: regular daily physical exercise increases insulin uptake, lowers blood sugar and aids weight control. Concentric exercise increases glucose uptake.
- Stress management (Jovic et al 2017) unmanaged stress and negative emotions have a negative effect on acne.
Are you ready to join our thriving Practitioner cohort?
This blog post was originally featured in Natural Dispensary Mag and is reproduced here, with some small changes, with permission. Our thanks to FDX Practitioner Fiona Trup for sharing her wisdom and enabling us to share this with you; so that you can use this in your practice to better support your clients.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883751/Kshetrimayum, 2019. Environment factors.
https://pubmed.ncbi.nlm.nih.gov/15943823/kumar, 2005 adrenal androgen excess
https://pubmed.ncbi.nlm.nih.gov/14671189/Altered cortisol metabolism. Tsilchorozidou, 2003
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5045492/Rosenfield, 2016)Theca cells.
Altered cortisol metabolism in PCOS.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818834/Khadilkah, 2016)Pcos is it time to rename pcos to HA-PODS.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672719/Goyal, 2017 Debates regarding lean patients.
Bunker CB, Newton J et all Most women with acne have pcos.
Fulghesu AM, Ciampelli M, Muzj G, et al. N-acetyl-cysteine treatment improves insulin sensitivity in women with polycystic ovary syndrome. Fertil Steril. 2002;77(6):1128‐1135. doi:10.1016/s0015-0282(02)03133-3
Broadhurst L, Polansky MM, Anderson, RA. Insulin-like biological activity of culinary and medicinal plant aqueous extracts in vitro. J Agric Food Chem. 2000 Mar; 48(3):849–52.
Grant P. Spearmint herbal tea has significant anti-androgen effects in polycystic ovarian syndrome. A randomized controlled trial. Phytother Res. 2010 Feb; 24(2):186-8.
Jamilian M, Samimi M, Mirhosseini N, et al. The influences of vitamin D and omega-3 co-supplementation on clinical, metabolic and genetic parameters in women with polycystic ovary syndrome. J Affect Disord. 2018;238:32‐38. doi:10.1016/j.jad.2018.05.027
Rodriguez-Moran M, Guerrero-Romero F. Oral magnesium supplementation improves insulin sensitivity and metabolic control in type 2 diabetic subjects. Diabetes Care. 2003 April; 26:1147-52.
Ansar H, Mazloom Z, Kazemi F, Hejazi N. Effect of alpha-lipoic acid on blood glucose, insulin resistance and glutathione peroxidase of type 2 diabetic patients. Saudi Med J. 2011;32(6):584‐588.
Leyden J, Stein-Gold L, Weiss J. Why Topical Retinoids Are Mainstay of Therapy for Acne. Dermatol Ther (Heidelb). 2017;7(3):293‐304. doi:10.1007/s13555-017-0185-2
Ashoush S, Abou-Gamrah A, Bayoumy H, Othman N. Chromium picolinate reduces insulin resistance in polycystic ovary syndrome: Randomized controlled trial. J Obstet Gynaecol Res. 2016;42(3):279‐285. doi:10.1111/jog.12907
McCarty M. High-chromium yeast for acne? Med Hypotheses. 1984;14:307–10. doi: 10.1016/0306-9877(87)90134-4.
Anderson RA, Broadhurst CL, Polansky MM, et al. Isolation and characterization of polyphenol type-A polymers from cinnamon with insulin-like biological activity. J Agric Food Chem. 2004 Jan 14;52(1):65-70
Dobrev H. Clinical and instrumental study of the efficacy of a new sebum control cream. J Cosmet Dermatol 2007;6:113-8.
Reddy V, Bubna AK, Veeraraghavan M, Rangarajan S. Saw palmetto extract: A dermatologist’s perspective. Indian J Drugs Dermatol 2017;3:11-3
Jović A, Marinović B, Kostović K, Čeović R, Basta-Juzbašić A, Bukvić Mokos Z. The Impact of Pyschological Stress on Acne. Acta Dermatovenerol Croat. 2017;25(2):1133‐1141.
Fiona Trup Dip Ion BANT CNHC trained at the Institute of Optimum Nutrition and has a special interest in Functional and Lifestyle Medicine.
Her specialist area is Medical Aesthetics and she is a Skin Specialist; running a Skin Clinic for the past 26 years in London.
Fiona regularly contributes articles on skin to the Only Natural Newsletter for Natural Dispensary.